Pericapsular Hip Block Guided by Ultrasonography in Elderly People with Hip Fracture in the Emergency Sector: Clinical Trial.

Objectives This study evaluated pain intensity in elderly subjects with hip fractures admitted to the emergency sector and undergoing preoperative pericapsular nerve group (PENG) block. Additionally, the degree of tolerable hip flexion was assessed. Methods A prospective, randomized, and controlled clinical trial with parallel groups. The control group consisted of elderly subjects with hip fractures undergoing standardized intravenous systemic analgesia. The intervention group consisted of elderly patients with hip fractures undergoing PENG block and standardized systemic analgesia. The groups were evaluated at rest and during movement using the Pain Assessment in Advanced Dementia (PAINAD) scale. We determined pain intensity and reduction, in addition to the degree of tolerable flexion of the fractured hip. All patient assessments occurred before the medication or block administration and at 45 minutes, 12, 24, and 36 hours postmedication or block. Results Preoperatively and 24 hours after PENG block, elderly subjects with hip fracture showed a significant reduction in pain at rest or movement compared to control patients ( p < 0.05), with 60% of patients assessed at rest demonstrating desirable pain reduction (≥50%) and only 13.3% of the control group achieving the desired pain reduction. During movement, after undergoing PENG block, 40% of subjects demonstrated the desired pain reduction and no patient from the control group. The intervention group also showed a significant improvement in the tolerable hip flexion group ( p < 0.05). Conclusion Preoperative PENG block in elderly subjects with hip fractures admitted to the emergency sector provided a significant reduction in pain compared with the control group.

Emergence of xylazine as a public health threat: what does the anesthesiologist need to know for perioperative care?

This paper explores the rapid emergence of xylazine exposure in the USA and its implications for anesthesiologists. Xylazine, a non-opioid sedative and analgesic often used in veterinary medicine, has increasingly been found as an adulterant in the illicit substance supply, leading to serious health implications. The pharmacological properties of xylazine, its clinical effects, and the challenges it poses for clinicans will be discussed. Perioperative strategies for anesthesiologists to manage these potential cases are provided. Furthermore, this paper necessitates an epidemiological understanding for detection and multidisciplinary collaboration in addressing this emerging public health threat. The manuscript concludes by emphasizing the role anesthesiologists will have to play in managing the clinical implications of xylazine and contributing to public health strategies aimed at curbing its misuse.

Neurological injury following peripheral nerve blocks: a narrative review of estimates of risks and the influence of ultrasound guidance.

BACKGROUND: Peripheral nerve injury or post-block neurological dysfunction (PBND) are uncommon but a recognized complications of peripheral nerve blocks (PNB). A broad range of its incidence is noted in the literature and hence a critical appraisal of its occurrence is needed. OBJECTIVE: In this review, we wanted to know the pooled estimates of PBND and further, determine its pooled estimates following various PNB over time. Additionally, we also sought to estimate the incidence of PBND with or without US guidance. EVIDENCE REVIEW: A literature search was conducted in six databases. For the purposes of the review, we defined PBND as any new-onset sensorimotor disturbances in the distribution of the performed PNB either attributable to the PNB (when reported) or reported in the context of the PNB (when association with a PNB was not mentioned). Both prospective and retrospective studies which provided incidence of PBND at timepoints of interest (>48 hours to <2 weeks; >2 weeks to 6 weeks, 7 weeks to 5 months, 6 months to 1 year and >1 year durations) were included for review. Incidence data were used to provide pooled estimates (with 95% CI) of PBND at these time periods. Similar estimates were obtained to know the incidence of PBND with or without the use of US guidance. Additionally, PBND associated with individual PNB were obtained in a similar fashion with upper and lower limb PNB classified based on the anatomical location of needle insertion. FINDINGS: The overall incidence of PBND decreased with time, with the incidence being approximately 1% at <2 weeks' time (Incidence per thousand (95% CI)= 9 (8; to 11)) to approximately 3/10 000 at 1 year (Incidence per thousand (95% CI)= 0. 3 (0.1; to 0.5)). Incidence of PBND differed for individual PNB with the highest incidence noted for interscalene block. CONCLUSIONS: Our review adds information to existing literature that the neurological complications are rarer but seem to display a higher incidence for some blocks more than others. Use of US guidance may be associated with a lower incidence of PBND especially in those PNBs reporting a higher pooled estimates. Future studies need to standardize the reporting of PBND at various timepoints and its association to PNB.

EEG response to a high volume (1.5 mL/kg) caudal block in infants less than 3 months.

INTRODUCTION: The substantial compression of the dural sac and the subsequent cranial shift of cerebrospinal fluid caused by a high-volume caudal block has been shown to significantly but transiently reduce cerebral blood flow. The aim of the present study was to determine whether this reduction in cerebral perfusion is significant enough to alter brain function, as assessed by electroencephalography (EEG). METHODS: Following ethics approval and parental informed consent, 11 infants (0-3 months) scheduled to undergo inguinal hernia repair were included in the study. EEG electrodes (using nine electrodes according to the 10-20 standard) were applied following anesthesia induction. Following a 5 min baseline period, a caudal block was performed (1.5 mL/kg), whereafter the EEG, hemodynamic, and cerebral near-infrared spectroscopy responses were followed during a 20 min observation period that was divided into four 5 min segments. Special attention was given to alterations in delta power activity since this may indicate cerebral ischemia. RESULTS: All 11 infants displayed transient EEG changes, mainly represented by increased relative delta power, during the initial 5-10 min postinjection. The observed changes had returned close to baseline values 15 min postinjection. Heart rate and blood pressure remained stable throughout the study. CONCLUSION: A high-volume caudal block appears to increase intracranial pressure, thereby reducing cerebral blood flow, to the extent that it transiently will affect cerebral function as assessed by EEG (increased delta power activity) in approximately 90% of small infants. TRIAL REGISTRATION NUMBER: ACTRN12620000420943.

[Evaluation of the quality of anesthetic recovery in postoperative patients]. / Evaluación de la calidad de recuperación anestésica en pacientes postoperados.

Background: Comprehensive health care includes the evaluation of satisfaction in patient care and the quality of medical services. High-precision instruments have been used to assess the quality of recovery after anesthesia (QoR), such as the QoR-15 questionnaire, a validated and accurate assessment tool that considers aspects of emotionality, physical and psychological well-being, pain, and autonomy. Objective: To assess QoR in postoperative patients who underwent anesthesia. Material and methods: Observational, descriptive, cross-sectional study, carried out from March to August 2022. 80 patients from 18 to 70 years who underwent an anesthetic procedure and to which the anesthetic quality QoR-15 questionnaire was administered 24 hours after surgery were included. Descriptive statistics were performed according to the Shapiro-Wilk test. For quantitative variables it was used Mann-Whitney U, and for qualitative variables chi-squared; it was considered significant a value of p < 0.05. Results: The 80 patients obtained a QoR-15 score of 122.06 (52-147), and their QoR was considered good. Anesthetic recovery quality in patients undergoing regional anesthetic techniques was excellent in 42.5% and 10% had balanced general anesthesia, p = 0.011. Conclusions: QoR was higher with regional anesthetic techniques. Quality assessment through validated tools allows objective evaluation and monitoring of the care process in medical services.

Introducción: la atención sanitaria integral incluye la satisfacción en la atención del paciente y la calidad de servicios médicos. Se han empleado instrumentos con alta precisión para evaluar la calidad de recuperación anestésica (CRA), como el cuestionario validado QoR-15, el cual considera aspectos sobre emocionalidad, bienestar físico y psicológico, dolor y autonomía física. Objetivo: evaluar la CRA en pacientes postoperados sometidos a anestesia. Material y métodos: estudio observacional, descriptivo, transversal, realizado de marzo a agosto de 2022. Se incluyeron 80 pacientes de 18 a 70 años sometidos a procedimiento anestésico y a quienes se les aplicó el cuestionario de calidad anestésica QoR-15 a las 24 horas de postoperados. Se empleó estadística descriptiva de acuerdo con la prueba de Shapiro-Wilk. Las variables cuantitativas se analizaron con U de Mann-Whitney y las cualitativas con chi cuadrada; se consideró significativo un valor de p < 0.05. Resultados: los 80 pacientes obtuvieron 122.06 (52-147) puntos en el cuestionario QoR-15 y su CRA se consideró como buena; en los pacientes sometidos a técnicas anestésicas regionales la CRA fue excelente en 42.5% y 10% tuvieron anestesia general balanceada, p = 0.011. Conclusión: la CRA fue mayor con las técnicas anestésicas regionales. La evaluación de la calidad mediante herramientas validadas permite su evaluación objetiva y hacer seguimiento del proceso de atención en los servicios médicos.

Identification of spread after deliberated intraneural injection in five mammalian species: not all animal models and needle types are valid for studying the effect of intraneural injections in humans.

INTRODUCTION: This research endeavors to investigate the phenomenon of intraneural spread across distinct locations: subcircumneurium, extrafascicular intraneural, intrafascicular intraneural, and intraperineurium after deliberate intraneural injections across five mammalian species. The study also aims to propose determinants influencing this spread. Furthermore, the investigation strives to ascertain the optimal animal species and needle configuration for extrapolating intraneural injection outcomes to human contexts. METHODS: This study examined 60 sciatic nerves from 30 fresh and untreated cadavers of rats, rabbits, dogs, pigs, and sheep. The specimens were organized into five groups, each comprising an equal number of nerves. Histological assessments were performed on 30 nerves, involving fascicle metrics. The remaining 30 nerves underwent intentional intraneural injections, facilitated by 19G and 23G needles under ultrasound and direct visualization guidance.Heparinized erythrocytes combined with a methylene blue solution were used as a marker to analyze the extent and patterns of intraneural spread. Needle orifice measurements were obtained, and these data were overlaid onto images of both nerves and needles. This enabled a comparative evaluation of sizes and an assessment of marker diffusion. RESULTS: The findings indicated that sciatic nerves in rats, rabbits, and dogs were oligofascicular, characterized by larger fascicles, whereas pigs and sheep exhibited polyfascicular nerves comprised of numerous smaller fascicles. Fascicular diameters were variable across species, with dogs presenting the largest measurements. While intraneural spread was observed and documented, intrafascicular marker spreading was rare, occurring only in one rabbit specimen. Needle orifice attributes were scrutinized and visually depicted. CONCLUSIONS: Despite the formidable challenges associated with the practical realization of intrafascicular injection, the utilization of animal models possessing monofascicular or oligofascicular nerves, such as rats, rabbits, and dogs, in conjunction with needles featuring aperture dimensions surpassing those of the fascicles, likely contributes to the compromised reliability of investigations into intraneural injection outcomes.

Clavipectoral fascia plane block spread: an anatomical study.

BACKGROUND: The clavipectoral fascia plane block (CPB) is a novel anesthetic management strategy proposed by Valdes-Vilches for clavicle fractures. This study aimed to investigate the distribution of the injected solution around the clavicle and the surrounding tissues. METHODS: Twelve clavicle samples were acquired from six cadavers. CPB was conducted using a 20 mL solution comprising methylene blue and iodinated contrast agent to improve visibility of the injected substance's dispersion. Methylene blue spread was assessed through anatomical dissection across distinct planes (subcutaneous, superficial muscular, deep muscular, and periosteal layers of the clavicle) in five cadavers. For the purpose of comparing methylene blue distribution, CT scans were performed on three cadavers. RESULTS: Methylene blue was detected in the medial, intermediate, and lateral supraclavicular nerves, as well as superficial muscles including the deltoid, trapezius, sternocleidomastoid, and pectoralis major. However, no staining was observed in the deep muscle plane, including the subclavius, pectoralis minor, and clavipectoral fascia (CPF). Anterosuperior periosteum exhibited staining in 54% of surface, while only 4% of the posteroinferior surface. CT images displayed contrast staining in anterosuperior periclavicular region, consistent with observations from sagittal sections and anatomical dissections. CONCLUSION: The CPB effectively distributes the administered solution in the anterosuperior region of the clavicular periosteum, superficial muscular plane, and supraclavicular nerves. However, it does not affect the posteroinferior region of the clavicular periosteum or the deep muscular plane, including the CPF.

Single-Shot Regional Anesthesia for Bariatric Surgery: a Systematic Review and Network Meta-Analysis.

PURPOSE: Laparoscopic bariatric surgeries can cause intense postoperative pain. Opioid medication can alleviate the pain but can have harmful side effects especially in patients with obstructive sleep apnea. To promote early recovery, enhanced recovery after surgery guideline advises minimizing opioid use and opting for alternative analgesics. This paper aims to investigate the effect of regional anesthesia techniques through a systematic review and network meta-analysis. Primary outcome is postoperative morphine equivalent consumption at 24 h. METHODS: Search was conducted in the following databases: PubMed, CENTRAL, Scopus, and EMBASE, from the inception until 10 January 2023. The eligibility criteria were determined by PICOS, including postoperative opioid consumption, pain scores, time to ambulate, use of additional analgesics, and adverse events. The quality assessment was performed using the Risk of Bias 2 Tool, and the certainty of evidence was assessed using the GRADE approach. Funnel plots were used to evaluate publication bias. RESULTS: We included 22 studies in quantitative synthesis. A review of 12 studies found that all techniques had a lower mean consumption of opioids compared to placebo or no intervention, with TAP block having the greatest reduction. The quality of evidence for postoperative pain, PONV, time to deambulate, and use of rescue analgesics, was rated as moderate, with TAP block being the most effective intervention. There was no publication bias in any outcome. CONCLUSIONS: TAP block is superior to other regional anesthesia techniques in reducing opioid consumption, pain, PONV, and use of rescue analgesics in bariatric surgery. However, further research is needed.

Pericapsular nerve group (PENG) block for early pain management of elderly patients with hip fracture: a single-center double-blind randomized controlled trial.

BACKGROUND: The pericapsular nerve group block (PENG) is a novel technique that blocks the articular branches of the hip joint. This study aimed to compare its effectiveness to a sham block in elderly patients with hip fractures. METHOD: A randomized double-blind controlled trial was conducted in elderly patients with intertrochanteric and neck of femur fractures. Patients were randomized to receive either PENG block or a sham block. Postblock, systemic analgesia was titrated using a standardized protocol of acetaminophen, oral morphine or patient-controlled analgesia. The primary outcome was the dynamic pain score (Numerical Rating Scale 0-10) at 30 min postblock. Secondary outcomes included pain scores at multiple other time points and 24-hour opioid consumption. RESULTS: 60 patients were randomized and 57 completed the trial (PENG n=28, control n=29). Patients in PENG group had significantly lower dynamic pain scores at 30 min compared with control group (median (IQR) 3 (0.5-5) vs 5 (3-10), p<0.01). For the secondary outcomes, dynamic pain scores were lower in PENG group at 1 hour (median (IQR) 2 (1-3.25) vs 5 (3-8), p<0.01) and 3 hours postblock (median (IQR) 2 (0-5) vs 5 (2-8), p<0.05). Patients in PENG group had lower 24-hour opioid consumption (median (IQR) oral morphine equivalent dose 10 (0-15) vs 15 (10-30) mg, p<0.05). CONCLUSION: PENG block provided effective analgesia for acute traumatic pain following hip fracture. Further studies are required to validate the superiority of PENG blocks over other regional techniques. TRIAL REGISTRATION NUMBER: NCT04996979.

Serratus plane block with sedation for patients submitted to axillary dissection: a prospective case series / Bloqueio do plano do músculo serrátil guiado por ultrassonografia associado à sedação venosa como técnica anestésica em cirurgia de linfadenectomia axilar: uma série de casos prospectiva

ABSTRACT Axillary dissection is a standard surgical procedure for stage III skin and soft tissue tumors and is usually performed under general anesthesia. This study aimed to investigate the feasibility of performing axillary dissection with Serratus muscle plane block plus intravenous sedation. Fifteen patients undergoing axillary dissection were prospectively recruited. The patients were evaluated during their pre-operative anesthetic appointment, during their procedure, and at post-operative days 1 and 30. The blockade was performed superficial to the Serratus muscle at the level of fourth rib. Sedation was performed using propofol, fentanyl, dexmedetomidine, and S-ketamine. None of the patients required conversion to general anesthesia. Surgeons showed a highly positive response when asked about the anesthetic technique, and most of them found the technique "indistinguishable" from general anesthesia. The median (interquartile range) pain scores at rest over all time frames was 0 (0-0). Furthermore, no patients developed nausea, hemodynamic instability, or any complications associated with the technique. The Serratus plane block associated with intravenous sedation proved feasible for axillary lymphadenectomy, however, further clinical trials should evaluate potential advantages compared to other techniques.

RESUMO A linfadenectomia axilar é um procedimento cirúrgico padrão para tratamento de tumores de pele e partes moles no estádio III e usualmente é realizada sob anestesia geral. A presente serie de casos prospectiva tem por objetivo investigar a viabilidade da realização da linfadenectomia axilar com o uso do bloqueio do plano do músculo serrátil anterior associado a sedação endovenosa. Foram incluídos 15 pacientes no estudo. Os participantes foram recrutados e avaliados durante consulta pré-anestésica ambulatorial, acompanhados durante o dia da cirurgia, no primeiro e no trigésimo dias de pós-operatório. O bloqueio foi realizado anterior ao músculo serrátil anterior ao nível da quarta costela na linha axilar média. A sedação foi realizada com o uso de propofol, fentanil, dexmedetomidina e dextrocetamina. Não houve necessidade de conversão para anestesia geral em nenhum paciente. Os cirurgiões apresentaram resposta altamente positiva quando questionados sobre a técnica anestésica, considerando na maior parte dos casos "indistinguível" da anestesia geral. A mediana (intervalo interquartil) da dor em repouso em todos os momentos avaliados foi 0 (0-0). Além disso, nenhum paciente desenvolveu náuseas, vômitos, instabilidade hemodinâmica ou qualquer complicação relacionada à técnica empregada. O bloqueio do plano do músculo Serrátil anterior associado a sedação venosa se mostrou viável para execução de linfadenectomia axilar, entretanto ensaios clínicos adicionais são necessários para avaliar potenciais vantagens em comparação com outras técnicas.

Anterior Quadratus Lumborum block area comparison in the three different volumes of Ropivacaine: a double-blind, randomized controlled trial in healthy volunteers.

BACKGROUND: In abdominal surgery, ultrasound-guided anterior quadratus lumborum blocks (QLB) are performed to induce analgesia. However, no study reported suitable volumes of the anterior QLB for the different postoperative analgesia regions. Therefore, this prospective randomized controlled study assessed the dermatomal spread and analgesic effects of the three different volumes of a local anesthetic for anterior QLB. METHODS: Ultrasound-guided anterior QLB was performed at the L2 level on 30 healthy volunteers. The volunteers were randomized to receive 20 ml (n = 10), 30 ml (n = 10), and 40 mL (n = 10) of 0.375% ropivacaine. The cutaneous sensory blocked area (CSBA), the number of block dermatomes, and the block duration time were measured by determining the extent of the cold sensation. RESULTS: The CSBA was significantly larger in the 40 ml group than in the 30 (P = 0.001; 1350.6 ± 234.4 vs. 1009.5 ± 151.6 cm2) and 20 ml groups (P < 0.001; 1350.6 ± 234.4 vs. 808.1 ± 120.5 cm2). Similarly, the number of blocked dermatomes was significantly higher in the 40 ml group than in the 30- and 20-ml groups. However, no significant difference was observed in block duration among the groups. CONCLUSIONS: No difference was observed in block duration with the various volumes of 0.375% ropivacaine. However, the larger volume for anterior QLB contributed to a larger area of cutaneous sensory blockade. Appropriate volumes in anterior QLB can create suitable postoperative analgesia levels for the different operative sites. TRIAL REGISTRATION: The study was registered in the Chinese Clinical Trial Registration Center on www.chictr.org.cn on 27th April 2018 (registration number: ChiCTR-IOR-17010853).